147_RW_Form_17_Applications_for__Ellington_Field_JRB_Contractor_Card.pdf

FROM: TO:

COMPANY NAME:

LOCATION/S OF WORK TO BE DONE ON THE INSTALLATION:

BADGE NUMBER:

DATE ISSUED: EXPIRATION DATE:

SIGNATURE OF BADGE ISSUING OFFICIAL:

SPONSOR PHONE#:

DAYS OF WEEK GRANTED TO WORK MON TUE WED THU FRI SAT SUN

HOURS OF THE DAY GRANTED TO WORK: CONTRACT DATES:

APPLICATION FOR ELLINGTON FIELD JRB CONTRACTOR IDENTIFICATION CARD

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C 8013 and Executive Order 9397 (SSN), as amended

PURPOSE: To request and record the issuance of contractor identification badges for Ellington Field JRB.

ROUTINE USE: DOD "Blanket Routine Uses" apply; SSN will be used to conduct a criminal background investigation through law enforcement.

DISCLOSURE: VOLUNTARY. Failure to provide the requested information will result in non-issuance of the contractor identification badge.

SECTION III: CERTIFICATE OF SPONSORING OFFICIAL (To be completed by Sponsoring Official)

LICENSE PLATE:#

and STATE

PRIVATELY OWNED

COMPANY OWNED

POLICY EFFECTIVE DATE:

POLICY EXPIRATION DATE:

VEHICLE MAKE:

NOTICE: While on this Installation, all personnel and property are subject to search. Controlled radioactive or explosive materials being brought onto Ellington Field JRB must first be approved by the 147 RW Safety Office.

147 RW FORM 17, 1 August 2012

SECTION IV: BADGE INFORMATION (To be completed by Badge Issuing Official)

SECTION II: CONTRACTOR VEHICLE INFORMATION

This section applies to contractors with a need to operate motor vehicles on the installation.

NOTE: To obtain a vehicle pass for the installation a valid copy of vehicle insurance must be presented to the badge issuing official. Vehicle owner must maintain current state certificate of registration and inspection for the vehicle operated.

SPONSOR SIGNATURE:

YEAR: MODEL: COLOR:

I certify that the applicant has an official/ authorized need for the contractor badge and has been briefed on its proper use.

NAME/ TITLE OF SPONSOR: BUSINESS ADDRESS OR MILITARY ORGANIZATION OF SPONSOR:

INSURANCE COMPANY NAME AND PHONE NUMBER:

SECTION I: CONTRACTOR INFORMATION

HOME ADDRESS: PHONE:

DL# and State:

CITIZEN: (Country)DATE OF BIRTH: SOCIAL SECURITY #

CONTRACTOR NAME: (Last, First, MI)

PRIVACY ACT INFORMATION: The information in this form is FOR OFFICIAL USE ONLY. Protect IAW the Privacy Act of 1974